History Of Gastroesophageal Reflux Disease Research Articles

Impact of patient and disease characteristics on the efficacy and safety of eluxadoline for IBS-D: a subgroup analysis of phase III trials.

Background:Irritable bowel syndrome with diarrhea (IBS-D) is a prevalent gastrointestinal (GI) disorder with a varied presentation, often overlapping with other GI and non-GI disorders. Eluxadoline is a locally active mixed µ- and κ-opioid receptor agonist and δ-opioid receptor antagonist approved for the treatment of IBS-D in adults. As IBS-D is a heterogeneous disease, factors such as patient demographics, symptom severity, and symptom pattern history can potentially inform treatment selection.Methods:Here, we report additional prospectively planned analyses of two large double-blind, placebo-controlled studies (IBS-3001 and IBS-3002) enrolling patients meeting Rome III criteria for IBS-D. Patients were randomized 1:1:1 to receive placebo or eluxadoline 75 mg or 100 mg twice daily. Efficacy (abdominal pain, stool consistency, and composite, simultaneous improvement in both) and safety were assessed for prospectively defined patient subgroups stratified by age, sex, race, presence of comorbidities, and baseline disease characteristics.Results:Across all age, sex, race, comorbidity, and disease characteristic subgroups, a greater proportion of patients were composite responders with both eluxadoline doses as compared with placebo, including patients with a history of depression or a history of gastroesophageal reflux disease. Among patients aged ⩾65 years, a greater proportion of patients receiving eluxadoline 75 mg were composite, abdominal pain, and stool consistency responders compared with those receiving 100 mg. The proportion of patients with at least one adverse event was slightly higher in patients aged ⩾65 years and also in female patients.Conclusions:This analysis suggests that eluxadoline is effective in treating IBS-D across a range of commonly encountered patient types. In contrast to the overall population, patients aged ⩾65 years demonstrated a greater proportion of responders at the lower approved 75 mg eluxadoline dose.

Gastroesophageal reflux disease and heartburn among the general population of Saudi Arabia

Background: Gastroesophageal reflux disease (GERD) is one of the most common upper gastrointestinal disorders that develop when a retrograde flow of stomach contents occurs leading to GERD symptoms or complications. The present study aimed at evaluating the prevalence of GERD and heartburn as well as their main characteristics and risk factors among the Saudi population, Saudi Arabia. Methodology: A cross-sectional study was carried out on a random sample of the general population of Kingdom of Saudi Arabia, during the period from 1 January to 16 June 2019, using a pre-designed questionnaire for data collection. Results: The study included 1734 participants; the majorities (76.8%) of the participants were females. The study reported that 17.8% of the Saudi population had GERD. There was a significant correlation between GERD and gender, age, BMI group, marital status, region and family history of GERD (P>0.05) but, there was no relation with average family income. It was more prevalent among females by 73.1% and among the age group 31-40 years by 32 %. Further, 38.8% of cases were with average weight, and more than half were married (57.6%). Conclusion: The study concluded that 17.8% of the Saudi population had GERD. There was a significant correlation between GERD and gender, age, obesity, marital status, region, and family history of GERD.

Prevalence and risk factors of gastroesophageal reflux disease among Shaqra University students, Saudi Arabia.

Introduction:Gastroesophageal reflux disease (GERD) is one of the most common chronic gastrointestinal disorders in adults, it develops when the stomach contents reflux and rise up into the esophagus as a result from lower esophageal sphincter dysfunction. Stomach acid that touches the lining of the esophagus causes symptoms and complications. The classical symptoms of GERD include heartburn, usually after eating, chest pain, and regurgitation.Aim:To measure the prevalence of gastroesophageal reflux disease and determine its risk factors among the students of Shaqra University.Methods:A cross-sectional study was conducted using a structured questionnaire distributed among Shaqra University students after multistage stratification and random sampling technique to stratify students according to gender and the three main colleges in Shaqra city, Saudi Arabia. The sample size was determined to be 435 with the precision of ± 5% and a 95% confidence interval (CI). The questionnaire included demographic data like age, gender, height and weight, lifestyle, and dietary habits. Statistical data were analyzed using the Statistical Package for Social Sciences (SPSS) version 16. Results with a P value of <0.05 were considered statistically significant.Results:A total of 400 [227 (56%) male and 173 (43%) female] participants were evaluated. And 95 participants got a gastroesophageal reflux disease questionnaire score of ≥8 thus determining the prevalence of GERD to be 23.8%. Univariate analysis revealed that gender, smoking, familial history of GERD, high body mass index (>25 kg/m2), fast food, tea, carbonated beverages consumption, quick eating, and sleeping within 1 hour of dinner are associated with symptomatic GERD (P < 0.05).Conclusion:The results show a high prevalence of GERD in Shaqra university students and the presence of many modifiable risk factors which merits the conduction of public health campaigns to raise awareness about the disease and its risk factors.

Self-reporting versus clinical scrutiny: the value of adding questionnaires to the routine evaluation of seizure disorders. An exploratory study on the differential diagnosis between epilepsy and psychogenic nonepileptic seizures

Questionnaires or symptom lists have proved effective for differentiating epileptic seizures (ES) from psychogenic nonepileptic seizures (PNES). However, monitoring the events, corroborated by medical history gathered by experts, remains the gold standard.We directly compared symptoms and characteristic of the events self-reported by patients/eyewitnesses (Questionnaire A/B) with the information contained in the clinical charts of 50 patients with undefined diagnosis undergoing long-term monitoring. Data extracted from medical records were reformatted to fit the questionnaires' templates (A1/B1) for comparison.Quantitatively, self-reported information was considerably greater and more complete. Calculating sensitivity (SE) and specificity (SP) of all variables in the group with confirmed diagnosis, we identified those above the preset thresholds with the potential to discriminate between ES and PNES.Eight predictive variables were common to both methods: head injury, physical/emotional abuse, chronic fatigue (A); talked out of seizures, eyes closed, apnea, and collapsing (B).Eleven predictive variables were specific to direct questioning: preictal headache, bright light, feeling overwhelmed, heart racing, tingling and numbness, postictal trouble speaking, physical pain, history of gastro-esophageal reflux disease (GERD), self-inflicted injuries (A); on/off shaking, and side-to-side head movements (B).Thirteen predictive variables were generated by chart review: sleep deprivation, strong emotions/anxiety, preictal headache (warning), nausea/vomiting, history of PNES, cholecystectomy, depression, medications for behavioral problems (A1), sudden start/sudden stop of shaking, both sides shaking, falling during the seizure, feeling confused and disoriented postictally (B1). ConclusionSelf-reporting and clinical scrutiny are complementary. Structured questionnaires increase the range of predictive variables and should be utilized routinely to facilitate clinicians' quest for the correct diagnosis.

Gastroesophageal reflux disease increases the risk of chronic rhinosinusitis: a nested case-control study using a national sample cohort.

The purpose of this study was to evaluate the relations between gastroesophageal reflux disease (GERD) and chronic rhinosinusitus (CRS) in a Korean population. Subjects from the Korean National Health Insurance Service-National Sample Cohort, all ≥20 years old, were assessed from 2002 to 2013. In total, 23,489 CRS participants were matched with 93,956 controls at a ratio of 1:4 with respect to age, group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed previous history of GERD in the CRS and control groups. The CRS group included patients identified using International Classification of Diseases 10th edition (ICD-10) codes (J32) who had treated their CRS ≥2 times and had undergone head and neck computed tomography (CT). The GERD group included patients identified using the ICD-10 (K21) code who had treated their GERD ≥2 times and had taken a proton pump inhibitor (PPI) for ≥2 weeks. Crude and adjusted odds ratios (ORs) were analyzed using unconditional logistic regression analyses. The 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed according to age and sex. The rate of GERD was higher in the CRS group (17.1% [4020 of 23,489]) than in the control group (9.1% [8522 of 93,956]; p < 0.001). The adjusted OR of GERD was 2.04 (95% CI, 1.96-2.13; p < 0.001) in the CRS group. The results of the subgroup analyses were consistent. The ORs of GERD were increased in CRS participants. This relationship was consistent in all age and sex groups.

Gastroesophageal Reflux Frequency, Severity, Age of Onset, Family History and Acid Suppressive Therapy Predict Barrett Esophagus in a Large Population.

To identify risk factors associated with Barrett esophagus (BE) for potential improved surveillance and risk reduction. Gastroesophageal reflux disease (GERD) is a known risk factor for esophageal adenocarcinoma, but the ability of GERD symptom frequency and severity to predict presence of its putative precursor lesion, BE, is less well-defined in large, community-based populations. We conducted a case-control study within the Kaiser Permanente Northern California population. Cases had new diagnoses of BE. To identify risk factors in the general population, we contrasted cases with population controls; to identify risk factors only among patients with GERD, we contrasted cases with GERD patients who lacked BE. We interviewed 953 patients; 320 patients with BE, 316 patients with GERD who lacked BE and 317 population controls. Compared with population controls, BE risk was highest among patients with the most frequent and severe GERD symptoms [odds ratio (OR), 27.00; 95% confidence interval (CI), 14.52-50.21], nocturnal symptoms (OR, 5.40; 95% CI, 3.81-7.72), and family history of GERD (OR, 2.55; 95% CI, 1.80-3.62) or BE (OR, 10.08; 95% CI, 2.83-35.84). Although at least weekly proton pump inhibitor (PPI) use was a risk factor for BE (OR, 9.85; 95% CI, 6.54-14.84), among PPI users in the general population, GERD symptoms were not strongly associated with the risk of BE. Compared with GERD controls, cases were more likely to have onset of GERD symptoms before 30 years of age (OR, 1.93; 95% CI, 1.15-3.22) and a family history of BE (OR, 3.64; 95% CI, 1.50-8.83). Severe and frequent GERD symptoms are strongly associated with increased risk of BE in the general population, especially in the absence of frequent PPI use. Among people with GERD, family history of BE and early age of symptom onset were stronger predictors of BE. These findings may improve identification of patients at highest risk for BE.

Gastric Heterotopia in the Rectum: Donʼt Let Looks Deceive You

Gastric heterotopia in the rectum is an extremely rare gastrointestinal entity with very few cases reported in the literature. Although it is an uncommon finding, it can lead to serious complications including rectal bleeding, rectal and abdominal pain, and most importantly, an increased risk for malignant transformation. Here we present a very rare case of an asymptomatic patient diagnosed with gastric heterotopia of the rectum after an initial screening colonoscopy. This is the case of a 51 year-old male with a medical history of gastroesophageal reflux disease that was seen at gastroenterology clinics for initial screening colonoscopy. At evaluation the patient was asymptomatic, denying weight loss, abdominal pain, diarrhea, constipation, melena, hematochezia, rectal pain, or changes in stool caliber. The patient had no pertinent family history and the only medication taken was omeprazole twice daily. On examination, vital signs were within normal limits and his physical did not reveal any abnormal findings. Laboratory tests were unremarkable. Colonoscopy was performed without complications and revealed four diminutive sessile polyps measuring < 0.5 cm at 2cm from anal verge (Figure 1). The histopathological evaluation revealed that all four were hyperplastic polyps (Figure 2). However, one small focus of pyloric glands and overlying foveolar type epithelium was identified (Figure 2-3), consistent with heterotopic gastric mucosa of the rectum. Gastric heterotopia refers to the presence of normal gastric mucosal tissue located in a non-physiological site, entirely apart from the stomach. It can occur anywhere along the gastrointestinal tract with most common sites being the esophagus and duodenum. However, the presence of gastric mucosa in the rectum is exceedingly rare with only approximately 50 cases described in the literature. Symptoms include painless rectal bleeding, rectal and abdominal pain. Rectum involvement of gastric heterotopia is usually observed endoscopically as a polyp, diverticula or ulcer. Histopathology is essential for diagnosis, with oxyntic type mucosa typically observed. Other histologic findings include mixed oxyntic, antral mucosa and pyloric type mucosa from which adenocarcinoma can arise. These lesions have an increased risk of malignancy, which warrants great awareness by physicians and close follow up. Here we observe that these lesions can present like a typical polyp, making biopsies an essential part of any colonoscopy.1494_A Figure 1. Diminutive sessile polyp at rectum.1494_B Figure 2. (A) Focus of pyloric glands with overlying foveolar type epithelium. (B) Hyperplastic polyp with superficial serrated architecture.1494_C Figure 3. Pyloric type gastric mucosa in rectum

Spinal Metastases: An Initial Presenting Sign of Signet Ring Cell Adenocarcinoma

Although gastric cancer detection has improved with the advent of successful treatments for gastroesophageal reflux disease and Helicobacter pylori infections, atypical presentations of this malignancy have still been identified. Cases of metastatic disease as the initial presentation of gastric malignancy have been uncommonly identified in the literature. We present a case of a patient that was admitted to our facility with initial symptoms of constipation and cervical spine pain and was found to have diffuse signet ring cell adenocarcinoma with spinal metastatic disease. A 67-year old female with a past medical history significant for chronic obstructive pulmonary disease and cocaine abuse was admitted for management of cervical spine pain after sustaining a mechanical fall complicated by quadriparesis. At the time of presentation, the patient did endorse a 10-pound weight loss over several months, but attributed this to her methamphetamine use. She denied any symptoms of persistent epigastric pain, melena, hematemesis, abdominal discomfort, loss of appetite, or nausea. The patient had no history of gastroesophageal reflux disease, alcohol abuse, Helicobacter pylori exposure, peptic or gastric ulcer disease at time of presentation. Subsequent spinal imaging noted presence of a pathological C2 fracture as well as several lytic lesions in the cervical spine concerning for metastatic disease. A CT abdomen was obtained to identify a primary source for the lytic lesions and noted presence of diffuse peripancreatic lymphadenopathy as well as thickening of the gastric antrum. Esophagogastroduodenoscopy identified a fungating mass near the gastroduodenal junction which revealed a differentiated signet cell adenocarcinoma with duodenal invasion on pathological evaluation. The patient underwent a cervical fusion and laminectomy as well as radiation therapy with minimal improvement in her symptoms. Due to intolerance of radiation therapy, the patient declined further oncological interventions including palliative treatments. The association of a gastric carcinoma with spinal metastatic disease as the first symptom is extremely uncommon. Although the rates of diagnosis of gastric carcinoma have improved due to greater awareness and recognition of precipitating factors by primary care physicians and gastroenterologists, the prevalence of signet ring cell adenocarcinoma is rising, and atypical presentations of this malignancy should still be considered.

Primary Diffuse Large B-Cell Lymphoma of the Descending Colon: A Rare Presentation

Primary non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (GI) is rare with incidence of 10-15% of all NHL cases and 1-4% of all GI tumors. The most common sites of involvement include the stomach, small intestines, colon and rectum. The presentation is usually non-specific leading to delay in diagnosis. A 49-year-old male patient with history of gastroesophageal reflux disease (GERD) presented with a 3-month history of abdominal discomfort and early satiety, this was associated with fatigue, night sweats and 20 lbs weight loss. On physical examination, he had tender right sided cervical lymphadenopathy (LAD) with several palpable, tender abdominal masses. Laboratory work up was significant for microcytic anemia with hematocrit of 39.8, mean corpuscular volume (MCV) 79.8, iron level 42 and iron saturation 11.1%. Ultrasonography (US) of the abdomen showed LAD near the umbilicus. Given his symptoms and laboratory work up, he underwent a colonoscopy that showed a single 1 cm ulcer in the descending colon (Fig. 1). Biopsy of the ulcer showed cells with expansion of the lamina propria by large atypical lymphocytes with irregular nuclear contour, single prominent nucleoli and moderate cytoplasm. Immunohistochemical stains of the cells were positive for CD20 and CD79a. The final diagnosis was diffuse large B-cell lymphoma (DLBCL), germinal center B cell-like (GCB) subtype. Positron Emission Tomography - Computed Tomography (PET-CT) was positive for uptake in cervical, mediastinal, and abdominal nodes. He was started on combination chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). He finished 6 cycles of R-CHOP with a negative repeat PET-CT consistent with remission.1550 Figure 1 No Caption available.Primary colorectal lymphoma is rare representing only 0.2 — 0.6% of all colorectal malignancies. The most common symptoms at presentation are abdominal pain and weight loss. DLBCL is the most common histological subtype. Computed Tomography (CT), US and PET-CT are helpful in suggesting the diagnosis by locating the tumor and its extension. Colonoscopy usually shows a fungating mass, infiltrative or ulcerative lesions. Distinct types of DLBCL are identified by gene expression profiling with the most common subtypes are GCB and activated B cell-like (ABC) DLBCL. The GCB has better survival compared to ABC. Management of DLBCL usually involves chemotherapy, radiation, surgery or a combination with R-CHOP chemotherapy being first line.

Gastroesophageal reflux disease and its related factors among women of reproductive age: Korea Nurses\u2019 Health Study

BackgroundRecently, the number of patients diagnosed with gastroesophageal reflux disease (GERD) has increased in Korea. Risk factors of GERD include age, sex, medication use, lack of physical exercise, increased psychological stress, low or high body mass index (BMI), unhealthy eating habits, increased alcohol consumption, and cigarette smoking. However, few studies examined the major factors affecting GERD in women of childbearing age. Therefore, this study assessed the risk factors of GERD among 20,613 female nurses of reproductive age using data from the Korea Nurses’ Health Study.MethodsParticipants were recruited from July 2013 to November 2014. They provided their history of GERD 1 year prior to data collection, along with information on their demographic characteristics, health-related behaviors, diet, medical history, and physical and psychological factors. Of the total sample, 1184 individuals with GERD diagnosed in the year prior to the study were identified. Propensity score matching was used for analysis.ResultsCigarette smoking, increased alcohol consumption, low or high BMI, depression, and increased psychosocial stress were associated with the prevalence of GERD among Korean young women. Multivariate ordinal logistic regression analysis revealed significant positive relationships between GERD and being a former smoker; having a low (< 18.5 kg/m2) or high BMI (> 23 kg/m2); and having mild, moderate, moderately severe, and severe depression.ConclusionsSmoking, BMI, and depression were associated with GERD. To reduce this risk among female nurses, intervention strategies are required to help nurses maintain a normal weight and manage their depression.

P024Sensitization by stem cell infusion: A case study

A 70 yo male with patient medical history of gastroesophageal reflux disease, colonic polyps s/p resection, insulin-dependent diabetes mellitus, hypercholesterolemia, and biopsy-proven idiopathic pulmonary, was evaluated for lung transplantation. The patient denied any sensitization events including transplantation, transfusion, prior surgery, and infection during the initial evaluation. However, both phenotype ID beads based and single antigen beads based testing showed only one weak HLA-A2 antibody (MFI = 2500, cPRA = 0% for antibodies with MFI > 5000). 3 month later, we performed another single antigen testing and the patient became highly sensitized (cPRA = 94% for antibodies with MFI > 5000). MFI of HLA-A2 antibody soared to 21,000 and HLA-A2 was C1q binding antibody. The patient also displayed antibodies against HLA-A23, A24, A68, A69 and other HLA-A locus antibodies. In addition, the patient had antibodies against HLA-Cw7 and Cw17. We were puzzled by the development of strong antibodies without a clear sensitization event. We decided to repeat antibody testing on a new sample one month later. During this period, the patient acknowledged that he received stem cell infusion several times for his wellbeing. The repeated single antigen testing confirmed the previous antibody findings. After explanation, the patient agreed to stop stem cell infusion. Single antigen testing 6 wks after the last stem cell infusion showed that the antibody level remained high. A decision was made to wait to see if the antibodies would reduce over time. Unfortunately, the patient passed away one month since the last antibody testing. Stem cells infusion was thought to be at low immunological risk due to the low level of HLA expression, but this case demonstrated that stem cells can stimulate antibody production effectively. No HLA class II antibody was detected during the entire course, which is in consistence with the previous finding that HLA class II antigens are not expressed on the surface of stem cells.

Hypercalcemia due to milk alkali syndrome: An emerging cause of hypercalcemia: A case report and review of literature

Introduction: Hypercalcemia is relatively common in clinical practice. Primary hyperparathyroidism and malignancy accounts for more than 90 percent of all cases of hypercalcemia. Milk alkali syndrome which is hypercalcemia classically caused by ingestion of large amount of calcium and absorbable alkali which was once virtually disappeared as a cause of hypercalcemia has emerged as a third leading cause of hypercalcemia. We present a case of hypercalcemia secondary to ingestion of calcium carbonate tablets resulting in milk alkali syndrome.Case presentation: Patient is a 45-year-old female with history of gastroesophageal reflux disease came to the emergency department with complaints of dizziness, constipation, fatigue and confusion for 3 weeks. She was hypotensive to 83/53 mmHg at arrival. Significant laboratory results were - Potassium of 2.2 mmol/L (3.5-5.1 mmol/L), chloride 73 mmol/L (98-107 mmol/L), Bicarbonate 50 mmol/L (22-29 mmol/L), Blood urea 22 mg/dl (9.8-20.1 mg/dl), Cr 1.4 mg/dl (0.5-1.0 mg/dl), total calcium of 16.6 mg/dl (9-11 mg/dl), ionized calcium 2.02 mmol/L (1.15-1.33 mmol/L), PTH was low to 8.9 pg/ml (10-65 pg/ml). Arterial blood gas showed metabolic alkalosis. Extensive evaluation to find the cause of hypercalcemia was negative. Detailed history after initial stabilization, revealed that she had been taking 10 tablets of calcium carbonate tablets per day and 1 glass of milk daily for reflux symptoms for the last eight weeks. Based on the history and after ruling out all the other serious causes, diagnosis of milk alkali syndrome was made and patient was discharged with proton pump inhibitor with advice to avoid calcium carbonate. Her hypercalcemia responded well to fluid resuscitation.Conclusions: Milk alkali syndrome once a rare cause of hypercalcemia has emerged as a third leading cause of hypercalcemia in completely different scenario. It is important to evaluate the patient with proper history including the use of over the counter calcium supplements to determine the etiology of hypercalcemia. Our case highlights the importance of proper history taking in the evaluation of hypercalcemia and that not all the cause of severe hypercalcemia is secondary to malignancy.

Assessment of the Knowledge of Gastroesophageal Reflux Disease among the Saudi Population of Altaif City

Background: gastroesophageal reflux disease (GERD) ranks as one of the most common gastrointestinal disorders. Up to this date, no studies examined the level of health knowledge of Saudi population about GERD. Aim of the study: this study aimedto assess knowledge about GERD signs, symptoms and risk factors in Saudi residents of Altaif City. Methods: this minimal knowledge questionnaire that was distributed among the general public in Altaif City, Saudi Arabia. The questionnaire consisted of two sections: section 1 included personal data and section 2 explored the awareness and knowledge about the most common symptoms and risk factors of GERD. Only questionnaires without missing data were subjected to statistical analysis. Results: respondents who answered all the questions correctly represented 7.4%, while those who answered all wrongly were 1.5%. The mean proportion of minimal medical knowledge (MMK) score was 64.66%. Respondents with higher education (p < 0.001), medical background (p = 0.004) and health knowledge derived from books (p = 0.001) achieved the highest total scores. Sex, residence, marital status, and past/family history of GERD seemed not to affect the mean MMK scores (p = 0.277, 0.234, 0.970, 0.873 and 0.085 respectively). Conclusion: some symptoms (Globus sensation, dysphagia and odynophagia) and risk factors (Scleroderma and asthma) for GERD remained unknown to nearly half the participants. We recommend providing health information concerning GERD on the Internet or to prepare booklets to be distributed through the health care facilities.

Influence of working in auto factory on gastroesophageal reflux disease.

Present study aimed to evaluate association between job -related factors and gastroesophageal reflux disease (GERD) among Iranian auto factory's workers. Many of the gastrointestinal disorders may be caused as the result of stress-related occupations and biorhythm disruption. We performed a cross-sectional study on 3590 Iranian Auto factory employees. GERD symptoms, demographic information, work shift, work section and history of some gastrointestinal disease were asked from all employees by physician. Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) for GERD symptoms according to the potential risk factors. The prevalence of GERD was 25.57%, which was higher in rotatory shift (91.6%) than the fixed shift (8.4%) (P-value = 0.009). Smoking (OR: 1.31; 95% CI: (1.09, 1.57)), working in official section (P-value < 0.001), history of GERD (OR: 8.63; 95 % CI (6.53, 11.40)), history of peptic ulcer (OR: 2.96; 95 % CI (2.08, 4.20)), family history of gastrointestinal cancers (OR: 1.47; 95 % CI (1.19, 1.81)) were the factors associated with GERD symptoms. The prevalence of GERD in the rotatory shift was more than the fixed shift. Smoking, family history of gastrointestinal cancers and peptic ulcer could be associated with GERD symptoms. Working in the special job with high activity, may probably lead to decrease in the risk of reflux.

Torsion of a Wandering Spleen With Splenic and Gastric Varices Presenting as Abdominal Pain

A wandering or ectopic spleen (splenoptosis) is extremely rare with a reported incidence of less than 0.2%. It only accounts for less than 0.25% of patients undergoing splenectomies. It is an elusive clinical diagnosis due to the variable presentation ranging from an abdominal mass to abdominal pain. This is a case of a 29 year old female with acute abdominal pain from torsion of a wandering spleen. A 29 year old female with history of gastroesophageal reflux disease presented to the emergency room with a 3 day history of worsening abdominal pain and a sensation of an abdominal mass in the left upper quadrant. On evaluation, she was afebrile and hemodynamically stable, with splenomegaly greater than 10 cm below the left costal margin and left upper quadrant tenderness. The rest of the exam was unremarkable. The platelet count was 115 x 109/L. Computerized tomography showed torsion of an enlarged spleen measuring 15cm that was displaced inferiorly with abundant splenic and gastric varices. Laparoscopic splenectomy was done on the third hospital day. Intraoperatively, the spleen was found in the pelvis with a 720 degree counter clockwise torsion around the pedicle. The post-operative course was uneventful. A wandering spleen refers to its presence in a location other than the left upper quadrant. It may be due to the absence or underdevelopment of splenic supportive ligaments, or from abdominal wall laxity or hormonal effects. It is predisposed to torsion due its long pedicle. Some are asymptomatic, while others present with abdominal pain from torsion or splenomegaly from vascular congestion. Persistent torsion of more than 180 degrees can lead to splenic infarction. The index patient had chronic volvulus of the spleen given the presence of splenic and gastric varices. Imaging modalities are crucial because early clinical diagnosis is difficult. Splenectomy is recommended if there is infarction, vessel thrombosis, functional asplenia or hypersplenism. However, splenopexy is preferred if there is a viable wandering spleen to avoid post-splenectomy sepsis. In conclusion, timely diagnosis is important to avoid life threatening complications such as splenic infarction or gastric variceal bleeding. This case highlights the crucial role of imaging in the prompt diagnosis and treatment of this rare condition.

Jejunal Lymphangiectasia as Source of Obscure Gastrointestinal Bleed (GIB) and Its Endoscopic Management

Intestinal lymphangiectasia is a pathologic dilatation of the intestinal lymphatic vessels in the mucosal and sub-mucosal layers of the gastrointestinal tract. Protein loosing enteropathy is a common presentation, gastrointestinal bleeding is unusual. A 36-year-old woman with a history of gastroesophageal reflux disease was evaluated for a 3-month history of melena, 20 lb. weight loss, and fatigue. Physical examination revealed generalized pallor and mild non-rebound tenderness in the left upper quadrant. Laboratory data revealed macrocytic anemia with hemoglobin (Hgb) of 5.7 g/dl, MCV of 106 and reticulocyte count of 12.9%. Iron studies revealed iron deficiency anemia and anemia of chronic disease. Celiac panel was unremarkable. She refused blood transfusions due to religious beliefs. Given the presence of anemia, the patient underwent esophagogastroscopy and colonoscopy, both were unremarkable. She was started on subcutaneous darbepoetin and intravenous iron which initially improved her Hb to 7.0 g/dl but her fatigue and melena recurred. Capsule endoscopy showed mucosal changes compatible with lymphangiectasia with multiple areas of active bleeding with clots within the first two hours of the capsule endoscopy. Single balloon enteroscopy showed a 10-cm segment of extensive whitish linear plaques with polypoidal areas with slow oozing of blood in the proximal jejunum (Figure 1). Argon plasma coagulation (Figure 2) was used to achieve hemostasis successfully. Biopsy from the polypoidal whitish plaques were consistent with lymphangiectasia (Figure 3). Post procedure, her melena resolved and Hgb improved to 11.1g/dl with intravenous iron. Intestinal lymphangiectasia presenting with isolated GI bleed is very rare. Only a few case reports have been reported in the literature. To our knowledge, this is the first case reported in literature using APC as a treatment modality for actively bleeding biopsy proven lymphangiectasia.Figure: Jejunal lymphangiectasia with active bleeding.Figure: Argon plasma coagulation used to achieve hemostasis in jejunal lymphangiectasia.Figure: Jejunal mucosa with dilated lymphatic channels in lamina propria filled with protein-rich fluid.

Look Again if Your Suspicion Is High!

A 52 year old African American gentleman with past medical history of gastroesophageal reflux disease and hypertension presented to the hospital with two months history of worsening abdominal pain associated with nausea and vomiting, approximately 2 hours after eating. These symptoms were intermittently present for the past year occurred almost daily in the weeks prior to presentation. He noticed some weight loss, since clothes were becoming large during this period. On the day of admission, he vomited multiple times. On physical exam, he was tachycardic and hypotensive, with dry mucus membranes. Abdominal exam was firm, not distended, with diffuse abdominal tenderness and guarding, but no rebound tenderness. Approximately 800 mL of brown colored liquid was suctioned from NG tube placed in Emergency Room. CT abdomen without IV contrast showed dilated stomach with flecks of air within the stomach wall in the nondependent portion, with pneumatosis intestinalis, and portal venous gas (Fig 1 and 2). The etiology for CT findings was not clear at this point. Patient was admitted to SICU for fluid resuscitation and observation. An EGD was performed after clinical improvement and revealed approximately 1000 cc of clear fluid in the stomach. An ulcer was seen in pyloric channel with surrounding edema and inflammation preventing passage of the scope beyond the area (Fig 3). Multiple biopsies taken from this area and random gastric mucosa were negative for Helicobacter pylori or malignancy. After a week of PPI and supportive therapy, a repeat EGD with biopsies confirmed poorly differentiated invasive adenocarcinoma. Subsequent evaluation revealed no evidence of metastasis, with stage IIA gastric cancer. Gastric Outlet Obstruction (GOO) can result from mechanical (benign or malignant) or motility related causes. It is an uncommon disease that has become rare after identification of Helicobacter pylori and wide use of proton pump inhibitors. Malignancy, which was a rare underlying etiology of GOO has become the etiology for at least 50% of cases. Pancreatic adenocarcinoma and distal gastric cancer are the most common malignancies causing GOO. The purpose of this case report is to demonstrate that malignancy, given severity and usual aggressive nature of the disease, has to be excluded with confidence as the treatment and prognosis differ significantly from malignancy versus other causes. Our high suspicion made us repeat biopsy and has changed this patient prognosis.FigureFigureFigure

A Rare Case of Coincident Barrettʼs Esophagus in Untreated Achalasia

Achalasia is characterized by failure of the lower esophageal sphincter (LES) to relax, with high basal LES pressure as well as failure of esophageal peristalsis. The disease manifests with primary symptoms of dysphagia and regurgitation. In contrast, Barrett's esophagus is linked to chronic gastroesophageal reflux disease (GERD) that results from chronic acid exposure related to excessive relaxation of the LES. This makes coexistence of conditions unusual. We report a case in which achalasia and Barrett's esophagus were diagnosed prior to treatment for achalasia. A 31-year-old male with a five-year history of GERD presented for evaluation of progressively worsening symptoms. Reflux symptoms had increased in frequency with several episodes of vomiting. Lifestyle modifications were recommended and he was started on daily omeprazole. One year later, he continued to complain of reflux symptoms, though he had noted some improvement. He had difficulty swallowing, with regurgitation of undigested food. A barium esophagram suggested achalasia. Esophagogastroduodenoscopy demonstrated narrowing of the gastroesophageal junction with a dilated esophagus, as well as a short tongue of salmon-colored mucosa (Prague classification C0M1). Histology demonstrated intestinal metaplasia without dysplasia. High-resolution esophageal manometry demonstrated a pattern consistent with type II achalasia. Laparoscopic Heller's myotomy was recommended, but the patient declined intervention. He was treated with submucosal injection of botulinum toxin with temporary symptom relief. Barrett's esophagus and achalasia do not typically co-exist, as they result from opposing dysfunctions of the LES. When achalasia is treated, excess acid reflux may occur from the resulting laxity of the LES, eventually leading to Barrett's esophagus in some patients. However, the diagnosis of both conditions in an individual patient prior to surgical or endoscopic interventions is exceedingly rare. This case reinforces the importance of careful inspection of the distal esophageal mucosa in patients with achalasia, as a patient with Barrett's esophagus at baseline may be at increased risk of progression of the Barrett's segment following therapeutic interventions.

Surgical Treatment of Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy. The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD. The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique. When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.

Epidemiology and natural history of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is highly prevalent in Western countries, particularly when considering its most classic symptom that is heartburn. This symptom is very frequent in the community and ranges from 10% to more than 30%, according to the various population-based studies. This disease is much more represented in Europe and USA than in Asiatic countries. It has been shown that GERD prevalence increases in parallel with the remarkable growth of obesity, as this condition is able to favor all the pathogenetic mechanisms leading to it. Current information regarding the phenotypic presentation of GERD shows that there are two main phenotypic manifestations, that are erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter includes the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, a pre-malignant lesion potentially leading to esophageal adenocarcinoma. Data from medical literature on the natural history of this disease are scant and mainly retrospective, so the interpretation of them is very difficult. However, they seem to suggest that both NERD and mild esophagitis tend to remain as such overtime and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur only in a small number of cases, ranging from 0% to 30%, 10-22% and 1-13%, respectively. Future studies should help us in elucidating better the real transition from one category to another and to do this, we have to exclude from the world of GERD all the functional conditions that nowadays can be easily recognized by means of impedance-pH monitoring.